Do Long Work Hours for Medical Residents Jeopardize Patients?

A recent article in Public Citizen News takes the position that limiting work hours for medical residents is necessary to promote patient safety. This issue has been discussed and considered for years, with many hospitals and medical groups contending that such limits will reduce the depth and breadth of knowledge that residents need to become good doctors. Others contend that sleep-deprived residents make more bad decisions about medical care and jeopardize their patients’ health and safety.

Students who complete medical school and pass the qualifying examination become medical doctors, but in most states are not licensed to practice medicine. They can’t just “hang out a shingle” as a doctor and begin seeing patients. The requirement is that they must go beyond medical school to become “residents,” most often at a medical school or other facility. The residency is designed to give them from 2-4 years additional training, usually in a particular field of medicine in which they wish to practice. Examples would be radiology, cardiology, internal medicine, dermatology, etc.

The typical residency occurs at a medical school. There the residents often end up practicing medicine from day one of their residency. As they move through the residency program, their scope of responsibility expands and, by the time they are in their last year of residency, their scope of responsibility is often equivalent to that of the attending physicians at the particular institution. They are often also supervising residents who are at an earlier stage in their residency.

In years past, residents in hospitals often worked very long hours, at relatively low pay. It was not unusual for a resident to work 24-36 hour work shifts, with 8-12 hours in between. This was an obvious financial benefit to their hospital employer, since fewer residents could see more patients at less cost to the hospital paying their salaries. It also had some advantages to the attending physicians (usually on the medical school’s faculty) who had to spend less time actually seeing and caring for patients in the hospital.

Older doctors were often proud of the long hours they worked and some have resisted the trend to limit hours. They are like the Marine who boasts about the tough training program he had to undergo. But their argument is that long hours means the resident sees more patients in more different situations, and this contributes to the knowledge base needed to become a good doctor.

This issue is coming to a head with a task force of the Accreditation Council for Graduate Medical Education (ACGME) issuing a proposal that would allow first-year residents to work up to 28 consecutive hours. Opponents of the proposal point out that studies have shown that such long hours result in tired residents who are at greater risk of car accident, depression, and needle-stick and other injuries that can expose them to disease. And that just focuses on the residents themselves. Other studies show that medical residents, when sleep-deprived, put patients at risk because of poor thinking and error-prone medical decisions. Some groups are arguing for a cap of 16 hours per shift. But the opponents of such caps also argue that this means shorter shifts result in more transitions and “hand-offs” of patients between physicians, which can contribute to more medical errors.

There have been many studies showing the effect of sleep-deprivation on human behavior, such as driving or even just interacting with others. That is why there are strict limits on how long an airline pilot, train operator, or truck driver can work in one shift. Arianna Huffington, the author of “The Sleep Revolution,” has argued that “sleep-deprived doctors must make life-or-death decisions while dealing with long overnight shifts.” Whatever the final decision on work limits for residents, it will impact the residents, the attending physicians who supervise them, the medical facility that employs them and, most importantly, the patients who are under the care of the resident.